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Home Health DME and Supplies Exceptional Circumstances Provision for Medicaid Clients 21 Years of Age and Older

Last updated on 4/29/2020

This article has been updated. Click here to see the updates.

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective June 1, 2020, information on using Texas Medicaid’s Home Health Durable Medical Equipment (DME) and Supplies Exceptional Circumstances provision for Medicaid clients 21 years of age and older will become available. Requests for medically necessary DME and supplies not covered as a benefit under Texas Medicaid should be submitted through the Home Health DME and Supplies Exceptional Circumstances process. This process is limited to DME and supplies for which Federal Financial Participation is available.   

Home Health DME and Supplies Exceptional Circumstances Provision

Texas Medicaid’s obligation to consider coverage of medically necessary DME and supplies not otherwise covered as a Texas Medicaid benefit for clients 21 years of age and older is known as the Home Health Durable Medical Equipment (DME) and Supplies Exceptional Circumstances provision. This includes items listed as non-covered services in the Texas Medicaid Provider Procedures Manual (TMPPM) or any item of DME and supplies that isn’t already considered or listed as a benefit of Medicaid.

The Exceptional Circumstances provision is made available in accordance with: Texas Administrative Code (TAC) 42 CFR § 440.70 (b) (3) (v), and 1 TAC § 354.1039 (a) (4) (D).

Prior Authorization

Home Health DME and Supplies Exceptional Circumstances requests must be prior authorized.

The Home Health DME and Supplies Exceptional Circumstances provision is not an available process to pursue for clients who receive prior authorization denials for medical necessity or technical reasons (e.g., missing essential fields, incomplete documentation). Clients that have been denied prior authorization under these circumstances may appeal the decision through the regular fair hearing process.

Requesting Use of the Home Health DME and Supplies Exceptional Circumstances Provision

Providers may request to use the Home Health DME and Supplies Exceptional Circumstances provision by providing a written notice to TMHP if the written notice meets all the conditions outlined below. The notice must include:

  • A completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form or other required form (e.g. Special Medical Prior Authorization [SMPA], Oxygen Therapy Devices and Supply Form, Wound Care Equipment and Supplies, etc.) signed and dated by the prescribing physician along with a cover letter indicating use of the Home Health DME and Supplies Exceptional Circumstances provision;
  • The client's diagnosis and identification of specific medical needs that can only be met by the requested equipment or supply;
  • A clear, concise description of the DME or supply requested;
  • Letters of Medical Necessity (LOMN) from the client's prescribing physician and other clinical professionals, as appropriate, documenting alternative measures and alternative DME or supplies that have been tried and failed to meet the client's medical need(s), or have been ruled out, and an explanation of why it failed or was ruled out; and
  • Submission of either the manufacturer's suggested retail pricing (MSRP) for the DME or supply requested, or an invoice documenting the provider's cost.

Note: TMHP may request additional supporting documentation if it is determined necessary upon review.

Reimbursement and Billing

DME and supplies allowed under the Home Health DME and Supplies Exceptional Circumstances provision must be requested by providers using the most appropriate procedure code available and must be authorized by TMHP in order to be considered for payment.

For more information, call the TMHP Contact Center at 800-925-9126.